Provider Demographics
NPI:1558409375
Name:PLYLER, SAM (EDD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:PLYLER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 OKEMOS RD
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1663
Mailing Address - Country:US
Mailing Address - Phone:517-349-0515
Mailing Address - Fax:517-349-3755
Practice Address - Street 1:4747 OKEMOS RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1663
Practice Address - Country:US
Practice Address - Phone:517-349-0515
Practice Address - Fax:517-349-3755
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000679103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI620C3-4525OtherBCBS PI N